ACUTE RESPIRATORY INFEC TIONS (ARI)
Cough and difficult breathing are common problems in young children. The causes range from a mild, selflimited illness to severe, life-threatening disease. Most episodes of cough are due to the common cold, with
each child having several episodes a year. Hospital based statistic shows that about 13 percent in-patients deaths
of paediatric ward are due to pneumonia. The commonest severe illness presenting with cough or difficult
breathing is pneumonia.
Many studies conducted on the incidence of ARI in children under 5 conclude that annual incidence is similar in
developed and developing countries. A child in an urban area suffers six to eight bouts of ARI annually,
including cough, cold, rhinorrhoea, bronchitis, bronchiolitis, and pneumonia, whereas in a rural a child suffers
about three to five episodes per year. The variation of incidence is attributed to the presence in rural areas of
fewer environmental contaminants that irritate respiratory mucosa. Without adequate treatment, the child may
die within 4-5 days of onset of illness. Safe and relatively cheap and effective treatment is available for the
treatment of pneumonia. If the therapy is started early many lives can be saved.
ACUTE RESPIRATORY INFEC TIONS (ARI) indicate an infection of any part of respiratory tract of less
than 30 days duration and otitis media of less than 14 days duration. It includes acute episode of running nose
(cold), cough, ear discharge, hoarseness of voice, breathing difficulty, fast breathing and chest indrawing with
or without fever. On the other hand, chronic cough is one that lasts for 30 days or more. The common causes of
chronic cough are tuberculosis, asthma, foreign body, pertussis, HIV infection etc.
CLASSIFICATION OF ARI
1. Upper respiratory tract infections (AURI): include common cold, pharyngitis, laryngitis, tracheitis,
epigiotitis and otitis media.
2. Lower respiratory tract infections (ALRI): include bronchitis, bronchiolitis and pneumonias.
Determinants:
Agent:
Host
Risk factor: The high incidence of pneumonia in children, in conjunction with their other risk factors (malnutrition,
overcrowding, poor care in the home) contribute to the higher incidence of complications and mortality in the pneumonia
cases in developing countries. Other important risk factors include low birth weight, scarce or absent breastfeeding,
vitamin A deficiency, incomplete vaccinations, poor air quality in the home, and exposure to chills.
ACUTE RESPIRATORY INFEC TIONS (ARI) CONTROL PROGRAMME
Acute lower respiratory tract infection e.g. pneumonia is a serious life threatening illness with high mortality.
The mortality due to pneumonia can be reduced by timely diagnosis, adequate and effective management with
relatively cheap and effective antibiotics and good nutrition.
THE OBJECTIVES AND STRATEGY OF ARI CONTROL
The main goal of ARI control activities is to reduce mortality from pneumonia in children less than 5 years of age.
Strategy includes:
• Standard case management (SCM) by health personnel at all level
• Equip mother in early recognition of fast and difficult breathing and seek referral
• Reduce the inappropriate use of antibiotics and other drugs used to treat ARI.
• Reduction of ARI complications in the lower airways (pneumonia and bronchiolitis) through early diagnosis and
effective case management
•High sustain coverage with measles DPT and BCG vaccine.
• Surveillance of pneumonia case and deaths
CLINICAL ASSESSMENT
History taking include: Age, duration of cough and fever, antecedent history of measles or any other disease,
inability to drink, drowsiness, convulsing fast breathing, chest indrawing, abnormal sounds (e.g. stridor,
grunting), treatment if any.
Other history should include:





Exposure to someone with tuberculosis (or chronic cough) in the family
History of choking or sudden onset of symptoms
Known HIV infection
Immunization history: BCG, DPT, measles, Hib
Personal or family history of asthma.
Criteria for diagnosis:
1. Respiratory rate: The respiration rate may be counted by looking to exposed abdominal/lower chest
wall movement. Counting should be made for 1 minute when the child is calm. However, if the rate is
more than 60/ minute in a young infant (>2 months age), a repeat count should be made. Fast breathing
is a sign of pneumonia. Some time fast breathing may be absent in severe pneumonia if the child
become exhausted and effort need to expand the lung is too great
Fast breathing is present when the respiratory rate is:
 60 or more in a child less than 2 months of age.
 50 or more in a child 2 to 12 months of age.
 40 or more in a child 1 to 5 years of age
2. Lower chest wall indrawing: In normal breathing, the whole chest wall including the abdomen move
OUT when the young infant breathes IN. When chest indrawing is present, the lower chest wall goes IN
during inspiration. Only the soft tissue movement between the ribs or above the clavicle during
inspiration is not chest wall indrawing. Chest indrawing should be examined in a quite/clam baby or
while sleeping. Mild chest indrawing is normal in a young infant because the chest wall is soft. Severe
chest indrawing is very deep and easily detected. Severe chest indrawing is a sign of pneumonia and is
serious in a young infant.
3. Stridor is a harsh noise during inspiration, which is due to narrowing of upper respiratory passage
(oropharynx, subglottis or trachea) .The conditions are termed as croup commonly. If the obstruction is
severe, stridor may also occur during expiration.
4. Wheeze is a high-pitched whistling sound near the end of expiration. It is caused by spasmodic
narrowing of the distal airways. During the first 2 years of life, wheezing is mostly caused by acute viral
respiratory infections such as bronchiolitis or coughs and colds. After 2 years of age, usually it is due to
asthma. Sometimes children with pneumonia may present with wheeze. It is important always to
consider pneumonia as a diagnosis, particularly in the first 2 years of life.
5. LOOK for nasal flaring: Nasal flaring is widening of the nostrils when the young infant breathes in.
6. LOOK and LISTEN for grunting: Grunting is the soft, short sound a young infant makes when
breathing out. Grunting occurs when an infant is having trouble breathing.
7. Body temperature: Fever & Hypothermia
8. Nutritional status
9. Cyanosis
CLASSIFICATION OF ARI:
For the practical purposes the cases are classified as followed, which vary in different age group.
Child of aged 2 months to 5 years
1. No pneumonia, cough or cold
2. Pneumonia
3. Severe pneumonia
4. Very severe illness
Young infant (<2 month of age):
1. No pneumonia, cough or cold
2. Severe pneumonia- any pneumonia in young infant is considered as severe.
3. Very severe illness
Classification of the severity of pneumonia (2 month to 5 years)
Sign or symptom
Classification
Place of treatment and action and
No pneumonia,  Home care
 Cough
cough or cold
 No fast breathing
 No antibiotics is required
 No chest indrawing
Home care / Care at health center
Pneumonia
 Fast breathing
Give appropriate antibiotic for 5 days
Follow up in 2 days
Advise the mother when to return
Lower chest wall indrawing
Severe
 Refer urgently to hospital with first dose
pneumonia
of antibiotic
 Give recommended antibiotic
Pneumonia along with danger sign: Very severe
Admit to hospital
pneumonia
Not able to drink, Convulsion,
Give recommended antibiotic
Abnormally sleepy, Stridor or
wheeze in a calm child,
Central cyanosis,
Severe under nutrition.
No pneumonia, cough or cold
These are common, self-limited viral infections that require only supportive care. Antibiotics should not be
given. Wheeze or stridor may occur in some children, especially infants. Most episodes end within 14 days.
Cough lasting 30 days or more may be caused by tuberculosis, asthma, pertussis or symptomatic HIV infection.
Diagnosis: Common features:
Cough, nasal discharge, mouth breathing, and fever.
The following are absent:
Fast breathing
Lower chest wall indrawing
Stridor when the child is calm
General danger signs
Treatment
Home remedy
 Soothe the throat and relieve the cough with a safe remedy, such as a warm, sweet drink.
 Clear secretions from the child’s nose before feeds using a cloth soaked in water
 Relieve high fever with paracetamol
 Following medication are not indicated
o Antibiotic is (they are not effective and do not prevent pneumonia)
o Medicated nose drops
o Remedies containing atropine, codeine or codeine derivatives, or alcohol may be harmful
Follow-up
Advise the mother to:
• Continue feeding
• Watch for fast or difficult breathing and return, if either develops
• Return if the child becomes sicker, or is not able to drink /breast feed.
Pneumonia
Pneumonia is usually caused by viruses or bacteria, which may be fatal if remain untreated. Pneumonia is
classified as very severe, severe or non-severe, based on the clinical features, with specific treatment for each of
them. Pneumonia is usually caused by viruses or bacteria. Antibiotic therapy is needed in all cases. Severe and
very severe pneumonia require additional treatment, such as oxygen and other supportive treatment.
Diagnosis
 Cough or difficult breathing
 Fast breathing
 Signs of severe or very severe pneumonia absent
Treatment
 May be treated at home
 Cotrimoxazole (4 mg/kg trimethoprim / 20 mg/kg sulfamethoxazole twice a day) for 2 days or
amoxicillin (25 mg/kg 2 times a day). Cotrimoxazole is not routinely recommend for an infant below 2
years; this is given for severe pneumonia.
Pneumonia may be treated by health worker at home or subcentre with cotrimoxazole according to following
schedule.
Age/
Pediatric tablet
Syrup (Each 5 ml contain
Weight
(Trimethoprim 20 mg&
Trimethoprim 40mg&
Sulphamethoxazole 100 mg)
Sulphamethoxazole 200 mg)
<2 months
One tablet twice daily
Half spoon
(2.5 ml) twice daily
2 monthTwo tablets twice daily
One spoon
12 months
(5 ml) twice daily
1-5 year
Three tablets twice daily
Three spoon
(7.5 ml) twice daily
Give the first dose at the clinic and teach the mother how to give the other doses at home.
Follow-up
Encourage the mother to feed the child. Advise her to bring the child back after 2 days, or earlier if the child
becomes sicker or is not able to drink or breastfeed. If the breathing has improved (slower), there is less fever,
and the child is eating better, complete the 3 days of antibiotic treatment.
If the breathing rate, fever and eating have not improved, change to the second-line antibiotic and advise the
mother to return again in 2 days.
If there are signs of severe or very severe pneumonia need institutional care.
Severe pneumonia
Diagnosis
 Cough or difficult breathing plus at least one of the following signs:
a. Lower chest wall indrawing
b. Nasal flaring
c. Grunting (in young infants)
 Check that there are no signs of very severe pneumonia, such as:
— Central cyanosis
— Inability to breastfeed or drink
— Vomiting everything
— Convulsions, lethargy or unconsciousness
— Severe respiratory distress.
 In addition fast breathing may or may not be present
 Wheeze – First episode of wheezing often associated with severe pneumonia. However recurrent
episode of wheezing with chest indrawing is most often do not have severe pneumonia rather it is
frequently due do asthmatic condition.
Treatment
Refer the child to hospital with 1st dose of antibiotic if being treated by health worker
Antibiotic therapy
 Benzylpenicillin (50 000 units/kg IM or IV every 6 hours) for at least 3 days. When the child improves,
switch to oral ampicillin (50 mg/kg 4times a day). The total course of treatment is 5 days.
 If the child does not improve within 48 hours, or deteriorates, switch to chloramphenicol (25 mg/kg
every 8 hours IM or IV) until the child has improved. Then continue orally for a total course of 10 days.
 If it do not response to chloramphenicol give cloxacillin(25mg/kg/dose 6hly) and gentamicin
(2.5mg/kg/dose 8 hly) combination
Oxygen therapy
Symptomatic treatment for fever, wheeze
Supportive care -fluid and food
Very severe pneumonia
Cough or difficult breathing plus at least one of the following danger sign):
 Central cyanosis
 Not able to drink or breastfeed
 Vomits everything
 Convulsions
 Lethargic or unconscious
 Severe respiratory distress.
 Severe undernutrition (2mo-5 yr)
 Hypothermia (<2mo)
 Wheezing (<2mo)
In addition, some or all of the other signs of pneumonia or severe pneumonia may be present, such as:
 Fast breathing:
 Lower chest wall indrawing
 Nasal flaring with inspiration,
 Grunting (in young infants)
Treatment
Very severe illness may be due to meningitis, encephalitis, cerebral malaria severe pneumonia etc. Child having
signs of very severe illness must be treated in a hospital with facilities for oxygen and intensive care. Treatment
should be given according to diagnosis made.
Antibiotic therapy
 Give ampicillin (50 mg/kg IM every 6 hours) and gentamicin (7.5 mg/kg IM once a day) for 5 days;
then, if child responds well, complete treatment
 Alternatively, give chloramphenicol (25 mg/kg IM or IV every 8 hours) until the child has improved.
Then continue orally 4 times a day for a total course of 10 days. Or use ceftriaxone (80 mg/kg IM or IV
once daily)
 If the child does not improve within 48 hours, switch to gentamicin (7.5 mg/kg IM once a day) and
cloxacillin (50 mg/kg IM or IV every 6 hours), when the child improves, continue cloxacillin (or
dicloxacillin) orally 4 times a day for a total course of 3 weeks.
Oxygen therapy to all children with very severe pneumonia
Supportive care
 Fever (39 0C/102.2 0F) treated paracetamol.
 Wheeze is treated with rapid-acting bronchodilator
 Clear thick secretions in the throat
Treatment of Pneumonia in a child aged less than 2 months.
Cough, running nose and fever are not the usual features in young infants in pneumonia. There may be only fast
breathing/ indrawing chest. It is always severe and the low birth weight baby may die due to cold
stress/hypothermia even in hot climate. In this state it is very difficult to differentiate between severe
pneumonia, septicaemia and meningitis. But whatever it may be, treatment is the same.
Treatment:
These children are to be hospitalized. These children are to be treated with injection benzyl penicillin or
injection ampicillin and gentamicin. Here chloramphemicol is not the drug of choice.
 Inj. Benzyl Penicillin or Inj. Ampicillin + Inj. Gentamicin
 Maintain the body temperature
 Treat associated conditions if any
 Continue exclusive breast-feeding,
Management of case of Wheezing – with salbutamol ( 1 mgm 8 hourly orally after food)
Mothers must be advised on.
How to give antibiotics to the child in proper dosage.
Continue adequate feeding including breast-feeding in small quantity and in frequent intervals
Danger signs are to be explained to mothers so that she will recognize and will bring the child for treatment.
They are as follows:
- Difficult and rapid breathing.
- Chest indrawing.
- Refusal of feeds.
- Eating and drinking poorly.
- Excessive sleeping/drowsiness.
- Convulsion.
- Cyanosis.
PREVENTION OF PNEUMONIA
 Keeping young infants warm and away from draught.
 Exclusive breast-feeding upto 6 months of age.
 DPT, Polio and Measles vaccination at the appropriate age.
 Prophylaxis Vit.A.
 Hand washing before feeding and touching the child especially young infants.
 Smoke and dust free environment
 Maintain proper and adequate nutrition.